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Corporate Medicine and Quality

doctorJust this week I received a call from a pediatrician that he and one of his partners are closing their office and retiring early. Their third partner is quitting and going to work for a corporation. I keep hearing about small practices that are closing. Most all of these are physicians and independent nurse practitioners: non-proceduralists that cite well-meaning rules and regulations that are driving up the costs of running small practices. The small practices are literally being driven out of business.

We all agree that we would like to see a way to measure quality and to find alternative payment forms, but at what cost?  The cost of all of the reporting is becoming so expensive and so time consuming that small primary care practices cannot afford to stay open. Many of these primary care providers are looking for positions that do not involve patient care; some are starting boutique practices; and others are going into corporate medicine.

When was the last time you tried to get a new primary care physician?  If you can find one taking patients, you are fortunate if you only have to wait three months. You may have to wait even longer to see a specialist: five to six months. Then, you need to find one that will take your insurance. Many hospitals and corporations try very hard to find enough physicians to adequately serve their populations. They are also faced with a frequent turnover of physicians working for them. It may be that forcing physicians into large group practices may be the better way to go if we really want to measure outcomes. But will patients like it?  And if they don’t, will it have a negative effect on the individual’s health?

As leaders in health care quality improvement, we have many questions: Will we need to add many more parameters to measure quality? Will quality measures include the patient's point of view? When a patient becomes ill, how long will he need to wait to see his personal physician? Will he need to see the next provider in the queue? Or should he just go to urgent care or the emergency department?  As corporations struggle to try to personalize patient care, more and more obstacles are put in their path. And the cost becomes more expensive.
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Between the Upstream and the Downstream – The Proximal Impact of Social Determinants

Group of Young Adults

Back in March, Margy Wienbar wrote a blog on the Upstream Parable, describing the association between high school graduation rates and health status. In short, improved high school graduation rates are associated with improved health outcomes.

While improving high school graduation rates is a worthy cause for a variety of reasons, there have been a number of studies that demonstrate we can act to improve health and social conditions without having to go so far upstream, as it were. While conversations about the intersection of genetics, health care, and social, behavioral, and environmental influences are heating up, the changing payment environment provides an opportunity for us to 'put our money where our mouths are'.

Social determinants of health (SDH) are "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life." These conditions include socioeconomic status, education, the physical environment, and social support networks. In a recent article, U.S. states with a higher proportion of social spending relative to health spending demonstrated significantly better outcomes for several population health-type measures. But while SDH can have a substantial impact on health outcomes (estimates as high as 90 percent for some conditions), they are not funded in the same way as other health-related services. There are a number of reasons why these efforts are not aligned, but some recommended policy principles provide opportunities for us to bridge this gap without going very far upstream:

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Practicing What We Preach – Looking in the Mirror to Become Internal Change Agents

Meeting in board room

I have previously written about HealthInsight and to a lesser extent myself being a "change agent". A change agent from my perspective is a person and/or organization that aggressively challenges the status quo in health care to drive transformation, while at the same time understanding the world in which health care providers and organizations function.

The art and science of change management is complex, and the implementation of change is often times a stressful and painful endeavor. Giving up on realizing transformational change often seems the best option after experience resistance and heartache. Sometimes we default to the "devil" we know is better than the scary prospects of a radically redesigned system.

Recently, HealthInsight has experienced a tremendous amount of growth in the number and scope of contracts that involve working with physician offices. Using our historical approaches for designing the work, we formed a new team every time we were fortunate enough to get a new contract. This has resulted in at least five physician office teams at HealthInsight who are working with physician offices in our four-state region.

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Is Good “Old-Style Public Reporting” the Means of Transparency that Aims to Maximize the Quality and Cost of Care?

Doctor typing on laptop

I was always curious about finding the best and most efficient ways of using and disseminating quality and cost data, and this has been the focus of my work for the last 10 years. We first started public reporting efforts in New Mexico 12 years ago with our statewide Takes on Diabetes coalition with health plans. In 2010 we received funding from the Robert Wood Johnson Foundation to expand our public reporting efforts to ambulatory setting and involved our stakeholders and providers in the collection, analysis, and reporting of health care data to patients, providers, insurers, hospitals and policymakers. The question I always have is how we make this data useful for all of our stakeholders.

As a health care analyst, I've seen both the advantages and disadvantages to traditional public reporting. Properly done, public reporting offers several potential benefits: it could reduce information asymmetry between both patients and providers, and payers, promote competition between providers in the health care marketplace, apply pressure to reduce costs and improve quality, empower patients to be more active participants in their own care, and foster a culture of accountability, transparency and efficiency.1 However, to be successful, public reporting must use a framework that has credibility for both those being evaluated and those using the data. In any public reporting schema there are trade-offs between the transparency required for success, and confidentiality required to protect physicians from litigation and from unfair and invalid characterizations of their clinical practices. If public reporting data may be used in litigation, physicians are far less likely to comply, which may undercut public reporting initiatives. Ultimately, patients may be on the losing side of this situation due to the lack of potential quality improvement with traditional public reporting.

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Trouble with the Curve

Father and child playing baseball

My father raised me to have a love for baseball. He made sure I knew each of the Los Angeles Dodgers by name and jersey number, and by the age of seven, he made sure I could play the game. When I was first learning we never bothered with the tee; he would pitch to me and coach me after every swing. He pitched and I swung until I was a master—or until we were hungry. I remember I always had trouble with the curve ball. I could play first base, shortstop, I could bunt, even hit a home run or two, but getting a hit off a curve ball never made the list.

Recently I attended the American Healthcare Quality Association Quality Summit in Baltimore, Maryland, situated directly next door to the home of the Baltimore Orioles, Camden Yards. It's a beautiful stadium that can be seen from the conference hall with many conference attendees catching an Orioles game at the end of their day. Over the years I've attended a number of these conferences and have seen the stadium from the inside, but this year was different. As usual, the conference provided hours upon hours of sitting and information overload, but this year instead of being encouraged to do more, achieve more, and be more—we were encouraged to get comfortable working in difficult circumstances. Let there be no mistake, achieving more was still the goal – that had not changed. What was different was the idea that we can't get into the 'green' unless we can first be comfortable in the 'red'. For a moment it felt as though my father was still standing at the pitcher's mound and I was at bat attempting to hit that curve ball. As speakers from the Centers for Medicare & Medicaid Services (CMS) greeted the audience and set the stage for years to come, they asked us to pause and find comfort in discomfort - to get comfortable being uncomfortable. Not one but three CMS senior executives shared their personal stories of failure and how the transparency of their momentary lack of success encouraged them to learn more – faster.

As I sat there and listened I realized how uncomfortable I was just sitting there! How would I bring this back to my team? For years we've used the familiar 'green, yellow, red' color coding in our performance dashboards to provide quick and intuitive displays of progress (or lack thereof). Suffice it to say, the red was not a place we wanted to be. We did everything to avoid the red. Green was clearly the most desirable form of progress and yellow, while not red, was still a bit scary and safe at the same time. And then it hit me. The closer to red we were, the more creative we became. It wasn't as if our team couldn't manage failure – sure we could, we have. Instead, we were being asked to recognize that it is in time of struggle where we find our true potential. It is where we find sustainability. It is where we should be asking ourselves, "What is good about this seemingly bad situation?"

I left happy to take this refreshing perspective back to my team and wondered if they would be as surprised to hear it from me as I was to hear it from CMS. I know one thing for certain, I may still have trouble with the curve in terms of baseball pitches, but I think this curve ball might just be a home run.

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Complexity Theory of Fixing Health Care

Nurses

When I speak to students I relay the story of graduating from nursing school in the mid-70's and the faculty telling us we were going into a new health care system, it had been fixed-managed care was the answer. Well now 40+ years later I am saying my career has been focused on improving and fixing health care, and guess what we are not there yet!! Don't get me wrong - we have improved longevity in this country, improved diagnostics, technology and treatment, and yes we may even be closer to finding a cure for those long unsolved diseases such as cancer and Hepatitis C. However, this has all come at a cost without evaluating and redirecting the money flow within the health care system. I guess now the question should be will it ever be fixed? At this point I would say no, it will never be totally fixed, we may come up with solutions and address some of the problems but health care is such a dynamic environment and continues to evolve that, quite frankly, I believe we should look at it as a journey rather than a problem to be solved. So pack your bag and be prepared for the long journey (depending on where you are in your career)!

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Five Things That Hit Me as I Read the MACRA Proposed Rules

Group of three doctors

The health care world has been buzzing with discussion about the newly proposed rules around the landmark Medicare Access and CHIP Reauthorization Act (MACRA) legislation that passed in April 2015 with bipartisan support. One year later, the Centers for Medicare & Medicaid Services (CMS) unveiled a proposed implementation plan for this new law. MACRA aims to move the U.S. health care payment system from volume-based care to value-based care. The final rule is expected by year-end, which highlights the need to know a bit more about our road to value. I recently spent some time traveling, so I decided to dive in to the 962-page proposed rule. Here are five things I found interesting and wanted to share.

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Payment Reform: HealthInsight’s Work to Support Alternative Payment Models

Stethescope on money

With the recent announcement of the proposed MACRA (Medicare Access and CHIP Reauthorization Act) rules, health care payment reform is moving full steam ahead, away from the fee-for-service model we have all grown accustomed to and towards new, value-based payment models.

HealthInsight strives to keep our communities, stakeholders and local providers up-to-date on the issues that matter to them, and payment reform is no exception. It's not only important for providers to know how these changes impact them, but it's also important for patient's to understand that the way health care is received and paid for care is changing. Here at HealthInsight are working on many activities to help our communities thrive under the emerging models.

We work directly with providers in our communities, providing support through our Quality Innovation Network Quality Improvement Organizations (QIN-QIO) contracts with the Centers for Medicare & Medicaid Services (CMS), including helping to enroll eligible practices into the Transforming Clinical Practices Initiative (TCPI) and other contracts. We align our efforts to support practices in adopting changes to be ready for new payment model and are seeking funding to help both large and small practices be ready for MACRA when the first measurement period starts in 2017.

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Stretch Goals – Compliance or Inspiration?

Darts

It seems we are always being asked to do more with less. Employers expect higher productivity. Coaches and fans expect more wins. Contractors add higher goals for less money. We expect more weight loss and better fitness with less effort. Oh, and yes, make that long term and sustained. How do we get motivated to do all of this? Does "stretching" our goals inspire us to do better for longer?

The manifestations of motivation are persistent attention and effort to a priority or goal. People sometimes seem to have an innate reluctance to do the right thing- take care of their health, seek extra education, save for retirement and create new solutions. Mark Twain noted, "The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not." Younger children seem to do things for the fun of it; they bounce back up and charge forward faster after a fall or misstep. Perhaps replacing judgmental restrictive environments with more encouragement and nurturing could restore natural curiosity and enjoyment of learning and growing.

Educators and employers seem to work on the premise that rewards (gold stars, incentives) and punishments (time out, penalties) will drive sustained behavior changes for the better. Indeed, for simple tasks of short duration, they do work. For instance, a national pizzeria chain collaborated with public schools to offer children who read for 20 minutes every day for one month a coupon for a free pizza; more children read. The program's goal was not to feed children; the goal was to get children to do the behavior long enough to experience the intrinsic joy of reading for themselves.

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Measurement has its Place, but Doesn't Always Tell the Whole Story

Basketball Backboard

I love the game of basketball. There are all sorts of statistics collected – 2-point shots scored, 3-point shots scored, free throw percentage, field goal percentage, assists, rebounds, blocks, fouls, steals, turnovers, etc. The statistics often tell a lot of the story. Steph Curry, point guard for the Golden State Warriors, scored 402 3-point shots this season, setting a new all-time record. Most would view this statistic as success and he was voted the most valuable player in the professional leagues this year. Nevertheless, statistics don't tell the whole story in basketball. Rarely do we quantify hustle, such as getting up the court quickly; team work like sharing the ball with others; or sacrifice when a player dives for a loose ball. These efforts, which few track, are often as important as points scored. Statistics can be focused on, to some degree, successfully (e.g. tonight I'm going to try and get more rebounds in this game). But in my opinion, too much focus on the numbers can be debilitating. There comes a point where you have to go play the game, have fun, do the best you can and not worry about the numbers.

Just as the statistics in basketball don't tell the whole story, such is also the case in health care. I was intrigued by a quote I read recently in the New York Times by the scientific health care quality pioneer Avedis Donabedien whose main focus was on measurement. He said during the last days of his life, "the secret to quality is love."1 This was a man who was dedicated to health care statistics. There are areas in health care we don't quantify but are extremely important, such as time spent with a patient discussing end of life care, treating co-workers respectfully and timely follow up with results. Although hard to quantify, few argue against the direct health benefits of the health care professional who spends extra time listening to a patient who has just had a difficult life event.

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25 Years of Advancements: Change at HealthInsight and in Health Care

Open Road

Twenty five years ago I stepped into the HealthInsight office, then called Nevada Peer Review, in Las Vegas and began my career in health care improvement. I was thrilled to have an advanced piece of equipment—an IBM Selectric self-correcting typewriter. Staff used dumb terminals to verify patient information for our Medicaid and Medicare review work, and our health care analysts had very large computers taking up a good bit of space in their office. Within a couple of years, we all upgraded to PCs and before long, cables and cords were draped everywhere as we established our first company-wide network.

We’ve come a long way at HealthInsight, and as I reflect upon my 25 years here, I think about the advancements made in health care over that same time period, and which of those, in my opinion, have had the biggest impact. There are many, and I’m sure each advancement may resonate differently, depending on your own personal perspective. These are just a few that made my list—focused on either public policy impacting an individual’s ability to manage their own care or technology advances.

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Embracing the Cloud

People using laptop and iPad

We've all heard the words nimble, adaptive and security when it comes to information systems. We want those systems to be more nimble and adaptive to users, while ensuring that data and infrastructure remain secure. These needs are a key priority for HealthInsight as we strive to remain a trusted partner and leader in our field. We are constantly looking for ways technology can help us achieve these needs.

This is where cloud services can come in. Cloud services, as defined in Webopedia.com, are "services made available to users on demand via the Internet from a cloud computing provider's servers." These services can allow businesses to offload tasks such as server maintenance, storage needs and software licensing to cloud providers, at what is becoming a very compelling and competitive cost structure. Use of cloud services can allow the IT department to focus their work on strategic projects instead of the day-to-day tasks that infrastructure requires.

But IT isn't the only one that can benefit from this potential approach; the business can too. Moving key services like file storage to the cloud can create a centralized repository where data can be collected and accessed from a wide variety of devices. Cloud providers have a high degree of availability, so it's unlikely that users would ever be without their information. Imagine accessing a report on a laptop while another user is able to make changes to the same document from their iPad, while yet another user is able to pull up the latest version on their cell phone. The collaborative and productive possibilities are plentiful.

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Putting the “Health” Back in Health Care

Doctor with patient

You're not feeling well. You have a fever, a sore throat, an unusual pain. What do you do? You seek medical attention, of course. Why? Because when you are sick, you go to the doctor. But are there reasons to go to the doctor when you're not sick?

When my husband was 55, he went to his primary care doctor and suggested that it was probably time he got a colonoscopy (an initial one is recommended at age 50 and his mother had colon cancer), maybe an EKG or treadmill test (his dad had a massive heart attack at age 52), and maybe a shingles or pneumonia vaccination. His doctor said, "Why are you asking for all of this? I don't get paid for ordering or providing these services." In other words, "I provide sick care, not wellness/preventive care." Not only was his statement true, but in most cases, commercial insurance does not pay for services that are intended to prevent, not treat, a certain condition; so if patients want these tests, they have to pay for them themselves.

Fast forward to 2012. Medicare expanded benefits to their fee-for-service beneficiaries to include an annual wellness visit. This is a visit focused on maintaining and improving health, making a plan for preventive and screening care, and keeping the clinic up to date on all the care a patient is receiving. An annual wellness visit includes a review of all the medications a patient is taking, the names of all other doctors they are seeing and the patient's medical/family history. Among other things, the doctor conducts a screening for depression, assesses the patient's ability to perform activities of daily living, his or her risk of falling and any hearing impairment.

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Recycling: Forethought, Not Afterthought

Bag of recycling material

Recycling and forethought go hand in hand – deliberation, consideration and planning for our future.

One of the Albuquerque programs I am most impressed with is how our city has fostered a robust and visible recycling program. The City provides blue recycling bins and these blue bins, like soldiers in uniform, line our curbside every weekday morning.

HealthInsight has whole-heartedly embraced this program. Recycling is ubiquitous in our HealthInsight New Mexico office. We have set places for mixed and glass recycling and have incorporated taking these items for recycling as part of our kitchen duty rotation. Blue bins for material to be shredded are in every office suite. During the recent renovation of our offices, we recycled many hundreds of paper hanging file folders, manila file folders, and even the metal file cabinets that held those items.

A few months ago however, I noticed not everyone plans for the recycling of their plastic, paper and glass. My sisters and I went to an annual festival at a local park where we had a great time sampling all the wonderful food, listening to music and watching the kids play games and run around on the grass. It was when it was time to leave and we looked around for a place to recycle our bottles and plastic cups that we discovered there were no recycling bins. Instead, we saw clean-up crews throwing bulging plastic bags into a dumpster.

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Inspiring Ourselves

Hiker celebrating

Imagine you are in a position where you are expected to help people change unhealthy habits or otherwise maladaptive behavior. You're not expected to be a miracle worker, but you want to make a difference. Finding effective ways to help these people is important to you. Now, let's make the problem a little harder: the people you're expected to help know that it's in their best interest to change; they've known for some time. Many have made prior attempts to change and have been discouraged by their results.

You are not in an enviable position. It may be even worse than it seems. The very people you are expected to help might see you or what you have to say as being threatening to their sense of self-worth and become defensive. What can you do to help them change?

A recent study points to a simple and inexpensive technique that you might consider. In the field of positive psychology it is called self-affirmation. It works like this:

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The Alien in My Neck

Measuring blood pressure

In director Ridley Scott's iconic 1979 sci-fi horror film "Alien", a rather gruesome, extra-terrestrial creature suddenly and violently bursts from the chest of a crew member on a deep space mission—a scene as vividly unforgettable as it was unexpected.

A few months ago, I had a somewhat similar experience ... albeit mine occurred in an outpatient surgery center, and the circumstances were a bit less dramatic. Let me explain.

Last summer, I attended our annual wellness screening event at work. Happily, all my lab values—glucose, cholesterol, triglycerides, etc., as well as my blood pressure—were in favorable ranges. My wellness "Health Score" was excellent! Even so, in the months after the screening I had a recurring impression that I should get an annual medical exam with my primary care physician. After initially resisting the impression, I finally set the appointment.

As I fully expected, the outcome of my exam was very positive: no health issues or presenting conditions. "Fit as a fiddle." Then, just before ending the exam, the doctor decided to check my neck. "Oh ... you have a mass on your thyroid. Pretty large, actually." I had no idea.

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Care Options for the Frail Elderly

Mother and daughter

While at the California Dialysis Conference last week, I attended a thought-provoking session with a panel discussion between three medical directors from the largest dialysis organizations in the U.S. – Davita, Fresenius and U.S. Renal: Dr. Allen Nissenson, Dr. Dinesh Chatoth and Dr. Stan Lindenfeld, respectively. These physicians grappled with many issues affecting dialysis patients nationwide.

As the topic turned towards the Centers for Medicare & Medicaid Services' (CMS) goal to have alternative payment models implemented in 80 percent of the Medicare population by the year 2020, the trio discussed the benefits of the new renal Accountable Care Organization (ESCO), including the unquestionable benefit of providing integrated care for patients with kidney disease. While these doctors agree that cost savings are an ultimate driver, by providing comprehensive services including palliative care, our medical community will be able to provide an alternative to dialysis and have painfully honest conversations about the benefits and challenges of treatment, particularly for the frail elderly. Surprisingly, at least to me, frailty has a medical definition. Frailty is identified when a patient meets three out of five criteria: weight loss (10 or more pounds within the past year), muscle loss, a feeling of fatigue, slow walking speed and low levels of physical activity. With aging frailty comes naturally; patients over 75 represent our largest growing segment with chronic kidney disease – the precursor to kidney failure.

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Achieving a Work-Life Balance—is it Possible?

Man throwing papers

I have felt at many times my balance between work and life has been out of sync. I think it is something most people experience at one time or another during their working years; struggling to maintain balance between work, home and everything else.

Jeff Davidson, an expert in work-life balance, said, "Work-life balance is the ability to experience a sense of control and to stay productive and competitive at work while maintaining a happy, healthy home life with sufficient leisure. It's attaining focus and awareness, despite seemingly endless tasks and activities competing for your time and attention."

If you're finding it more challenging than ever to juggle the demands of work and the rest of your life, you're certainly not alone. We all need some breathing space each day with time to enjoy life, while still feeling a sense of accomplishment at our jobs. Perhaps the following will help bring a little more balance to your daily routine:

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Football Lessons on Leadership from Peyton Manning

Peyton Manning

I had the privilege of being in attendance at the annual conference of the Health Information Management System Society (#HIMSS16) in Las Vegas a few weeks ago when Super Bowl Champion Peyton Manning gave the closing keynote address. He shared insightful personal stories that resonated with health care transformation, involving leadership and teamwork. His perspective as a leader on the football field can help us as we consider what it takes to be successful teams and leaders in health care today.

He started by sharing that he felt that he could relate to the crowd of Health IT professionals in the room: "both football and health care require leadership in a world that spins on an axis and is constantly throwing hurricanes at us." He explained that the new word for nimble is pivot. He said "Pivot is the ability to change strategy without changing or losing the vision; being nimble to take whatever is thrown at you."

He shared how it felt to be learning on the run as he started out in the NFL. Peyton humbly shared that he set the single season record for most interceptions by a rookie quarterback. He joked that he is "still pulling for someone to break that record!"

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The Upstream Parable: What’s High School Graduation Got to do With it?

Classroom desks

I come from a background in public health where the upstream parable is often used to discuss the importance of prevention. The parable goes something like this:

A medical professor and his student are walking together along a river. As they walk, they discover a drowning man. The student immediately jumps in to save him. Farther along, a woman is drowning. Again, the student jumps in while the medical professor stands and watches. They continue walking and encounter two more people drowning in the river. Once again, the student dives in to save the people, and he barely survives with his own life. The professor just continues walking along the river.

Exhausted and infuriated, the student confronts the professor and asks, "Why didn't you help me? Those people were dying, and I barely made it out alive!" The professor keeps walking and says, "I'm going upstream to see why all these people are falling in the river."

Soon enough, the professor and student come across a bridge. People need the bridge to get to their farmlands across the river, but they are falling into the river because the bridge is in poor condition. The professor sets to work repairing the bridge.

Last October, the HealthInsight Management Corporation Board of Directors, and the respective Boards in each state, voted on a series of True North Measures to guide the work of the organization. The boards selected high school graduation rates as a True North Measure. This is an example of an upstream measure as there is a clear association between educational attainment and future success and health status.

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